Provider Demographics
NPI:1083044556
Name:KELLER, MATTHEW JACOB (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JACOB
Last Name:KELLER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 MOUNT EAST RD
Mailing Address - Street 2:
Mailing Address - City:CONNELLSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15425-6096
Mailing Address - Country:US
Mailing Address - Phone:724-309-7554
Mailing Address - Fax:
Practice Address - Street 1:860 ROSTRAVER RD
Practice Address - Street 2:
Practice Address - City:BELLE VERNON
Practice Address - State:PA
Practice Address - Zip Code:15012-1945
Practice Address - Country:US
Practice Address - Phone:724-929-3278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-20
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056387363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant